Managing disruptive behavioral symptoms: today's do's and dont's.

A guide through the regulations

The management of disruptive behavioral symptoms (DBS) in long-term care patients may occur in one of three approaches: non-pharmacologic, pharmacologic or a combination of the two. The Omnibus Budget Reconciliation Act (OBRA) requires careful usage, documentation and justification of the usage of pharmacologic agents for DBS in nursing home patients. In fact, most studies show little if any benefit to the use of drugs for DBS, especially the antipsychotics.

DBSs can be grouped as agitated behaviors and behaviors associated with psychotic symptoms of hallucinations, paranoia and delusional ideation. Agitated behaviors are more common in cognitively impaired patients, especially in patients with dementia of the Alzheimer's type (DAT). There are three groups of agitated behaviors: aggressive, physically nonaggressive and verbally agitated. Aggressive behaviors, such as inappropriate grabbing, kicking, biting and scratching, tearing and hitting, or abusive verbal actions such as cursing, may be the most justified usage of pharmacologic agents, when non-pharmacologic methods do not adequately control the aggressive behavior.

Physically non-aggressive behaviors include wandering, pacing, inappropriate handling objects or dressing/undressing, repetitive mannerisms or questions, and restlessness. This form of DBS should never be treated with pharmacologic agents.

Verbally agitated behaviors include repetitive complaining or requests for attention, repititive negative assertions and yelling. These DBSs rarely respond to pharmacologic treatment. Only constant yelling or screaming has any justification for medication, under the OBRA guidelines.

Behaviors associated with psychotic symptoms that are persistent do respond to antipsychotics, in particular, but should be treated with the lowest possible dosage.

Non-Pharmacologic Approaches to DBS

The most important aspect to DBS management is to train the staff of the nursing home to understand the nature of the typical DBS episode. In the cognitively-intact person, the DBS usually is a means of communication. For example, I recently observed a stroke patient who began to scream for the first time. The reaction of the charge nurse was to call the attending physician for an order to sedate the patient. On further checking the patient's situation, however, we found that the patient simply wanted to be changed, as she was wet due to her incontinence.

This illustrated that, in the cognitively-impaired patient (e.g. DAT), the primitive instincts may be the only remaining reactive component to the patients' psyche. Staffers who handle the patient must recognize the perspective of the demented patient who exhibits physically aggressive behavior only when he or she is to be showered or moved or dressed. Gentle manipulation of the patient, especially when undressing or exposing to water, may lessen the likelihood of DBS.

Alternative Therapies

The December 1992 issue of the journal Regimen emphasizes several non-drug alternative measures that call for creative interdisciplinary strategies to minimize DBS. These innovations include:

Multigenerational Approach -- this involves the usage of full-time child care centers in nursing homes. The older person can offer special experiences, interests and skills, and can benefit from providing the special attention children need from adults who have both the time and patience to listen to them. Pet Therapy is used to alleviate the sense of loneliness experienced by the elderly, and since many demented patients have intact memories of their early childhood days, pet therapy can give them a link with pleasant memories from their past.

Plant Therapy -- by allowing a nursing home resident to care for a plant, a meaningful opportunity to create a more homelike atmosphere is afforded.

Art Therapy -- gives a resident the chance to express themselves and their emotions even though they cannot verbalize.

Exercise and Dance Therapy -- can allow residents to improve mobility, circulation and self-esteem; also, confusion, loss of memory and depression can be improved with this form of alternative therapy.

Music Therapy -- is one of the most popular alternative therapies, which allows patients with various levels of cognition to experience many happy memories. An additional form of therapy is access to worship services, which give the resident a chance to express and experience their religious beliefs, regardless of the level of cognition.

Pharmacologic Approaches to DBS

The OBRA legislation requires that nursing facility patients be:

1. Free from unneccesary drugs OF ALL TYPES (remember that most drugs have a possibility to be psychoactive.)

Unnecessary Drugs are defined as:

a. Excessive dose b. Excessive duration c. Excessive adverse consequences d. Without adequate monitoring e. Any combination of the above

2. Free from chemical restraints (what are most commonly thought of as psychotropic drugs to include antipsychotics, antidepressants and anxiolytic and hypnotic meds). If antipsychotic drugs such as Haldol, Mellaril or Navane, are to be used they must be used appropriately.

Many times the drug regimen for the nursing facility patient includes medications that can affect cognition, mentation, alertness, and ability to perform activities of daily living (ADLs).

The table on the following page lists drugs -- an extremely wide variety of them -- that may be used, knowingly or not, as chemical restraints.

Approved Indications

The patient receiving an antipsychotic must have an indication from the following choices: Schizophrenia or schizo-affective disorder; delusional disorders; acute psychosis or mania with psychotic mood; brief reactive psychosis; atypical psychosis; Tourette's Syndrome; schizophreniform disorder; Huntington's chorea; short-term symptoms of nausea, vomiting, hiccups or itching; and dementia associated with psychotic or violent features that represent a danger to the patient or others.

As already mentioned, yelling may be considered to be an indication for medication, if it is constant and considered traumatizing to other residents. Of course the usage of an isolation room, in which all the "Yellers" or "Screamers" are placed, is preferable to sedation.

Antipsychotic drugs should NOT be used for the following:

* Restlessness, fidgeting, or wandering

* insomnia

* depression

* screaming or crying out

* anxiety

* memory impairment

* uncooperativeness

* agitation

* sedation or calming

* "inability to manage patient"

Reasons for the usage of antipsychotic drugs must be documented on the physician's orders or progress note and in the patient care plan.

Antipsychotic drugs MUST be used in the minimal dose necessary to control the above indications. This minimalization may be assured by:

1. Periodic tapering -- minimally, every six months -- by at least 25 % of the daily dose in an attempt to discontinue the drug if patient improvement is noted;

2. Using staff intervention to find out why the patient may have a behavioral problem;

3. Monitoring and documenting the HARMFUL patient target symptom or behavior (e.g. biting, scratching, kicking), and whether the target symptom is actually affected on a month-to-month basis by the antipsychotic;

4. Observing and documenting adverse effects (e.g. sedation, falls, worsened behavior or disorientation/confusion, extrapyramidal symptoms and tardive dyskinesia) on a monthly basis. The latter two movement disorders (EPS and TD) should be assessed at least every 6 months using an AIMS or similar scale.

5. The most common side effects of all drugs in use in nursing home patients must be made a permanent part of their charts.

Case Illustration

A case evaluation illustrates the OBRA-required documentation of harmful behavior and drug effects:

Case

L.L., an 83-year-old patient with advanced dementia, has engaged in kicking, biting and/or scratching over 21 episodes in the prior 3 months. She is placed on 0.5 mg haloperidol daily and has only 3 episodes of harmful behavior over the next 3 months. She has also fallen 3 times since being placed on the haloperidol. The Quality Assessment and Assurance Committee (QAAC), with consultant pharmacist input, recommends that the haloperidol be decreased to 0.25mg per day.

DRUGS USED AS PSYCHOACTIVE CHEMICAL RESTRAINTS (KNOWINGLY OR NOT)

Psychoactive Drugs Used in Nursing Homes

Antipsychotics -- Mellaril, Serentil, Thorazine, Navane, Haldol. Stelazine, Prolixin, Taractan, Moban, Loxitane, Trilafon*

Antidepressants -- Elvail/Endep*, Aventyl/Panelor, Vivactyl, Tofranil/SK Pramine, Norpramin/Pertofrane, Sinequan/Adapin, Ascendin, Ludiomil, Prozac, Wellbutrin, Surmontil, lithium, Clozaril, Anmafranil. AVOID MAOI TYPE A ALTOGETHER

Antiparkinsonism Agents -- L-DOPA, Sinemet, Symmetrel, Cogentin, Artane, Kemadrin, Benadryl, Akineton, Parlodel, Permax, Eldepryl

Antianxiety and Hypnotic Agents -- Librium, Valium, Dalmane, Miltown/Equanil, Tranxene, Paxipam, Centrax, Klonopin, Ativan, ProSom, Doral, Serax, Xanax, Halcion, chloral hydrate, Doriden, Noludar, Placidyl, Seconal, Nembutal, Amytal, Tuinal, Butisol, phenobarbital 

Antihistamines (Combination, cold/hay fever products with decongestants) -- Chlor-trimeton (Ornade, Isochlor), Dimetane (Dimetapp), Benadryl, Tavist, Ambodryl, Clistin, Decapryn, Polaramine, Forhistal, Actidil (Actifed), PBZ, Histadyl, Tacaryl, Phenergan, Temaril, Atarax/Vistaril, Optimine, Periactin, Seldane, Hismanal

Antinauseants--Phenergan, Tigan, Compazine, Torecan, Reglan, Trans-Scop, Antivert/Bonine, Marezine

Antidiarrheals -- Lomotil, Immodium, Donnagel, Parapectolin

Antisecretory -- Robinul, Donnatal, Levsin, Atropine, scopolamine, Pamine, Quarzan, Tral, Darbid, Cantil, Banthine, Pro-Banthine, Pathilon, Bentyl, Daricon, Ditropan, various combination products

Antiulcer Drugs -- Tagamet, Zantac, Pepcid, Axid

Analgesics -- Darvocet/Wygesic, Talwin, Percodan, Percocet, Lortabs, codeine, morphine, all narcotics

Antihypertensives (with central nervous system effects) -- Aldomet, Wytensin, Tenex, Catapres, Ismelin, Hylorel, reserpine, Inderal, Corgard, Tenormin, Blocadren, Lopressor, Visken, Normodyne/Trandate, Sectral, Levatol, Cartol, Isoptin/Calan/Verelan, Kerlone

Antianginals -- Isoptin/Calan, Cardizem, Procardia, Cardene, Norvasc, DynaCirc, Vascor

Antiarrhythmics -- quinidine, Pronestyl/Procan, Norpace, Tonocard, Tambocor, Mexitil, Cardarone, Enkaid, DecaBid

Anticonvulsants -- Dilantin, phenobarbital, Tegretol, Depakene/Kepakote, Mysoline, Karontin, Klonopin

CNS Stimulants -- theophylline products, caffeine, Trental, Ritalin, Cylert

* Indicates that these drugs may also be available in combination products

James W. Cooper, Pharm. PhD., FASCP, FASHP, is Professor and Assistant Dean at the University of Georgia College of Pharmacy, Athens, GA.